Provider Demographics
NPI:1205286168
Name:CERTIFIED MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:CERTIFIED MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-793-9763
Mailing Address - Street 1:3651 LINDELL RD
Mailing Address - Street 2:SUITE D651
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-1254
Mailing Address - Country:US
Mailing Address - Phone:702-851-5610
Mailing Address - Fax:702-943-0233
Practice Address - Street 1:603 E 8TH ST STE A
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6251
Practice Address - Country:US
Practice Address - Phone:360-406-5063
Practice Address - Fax:360-477-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604-000-651332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7576770001Medicare NSC